CONFIDENTIAL PATIENT INFORMATION



CONFIDENTIAL PATIENT INFORMATIONFull Name: Date:Address: Home Phone: Work Phone:Cell Phone:Email Address:Date of Birth:Age:# of Children:Pregnant? □ Yes □ NoMarital Status: M S W DSpouse/Guardian Name:Occupation:Employer’s Name:Phone Number:Emergency Contact Person: Relationship:Phone Number:*Acupuncture will only be billed through insurance if you have a Blue Cross Blue Shield federal policy*Who may we thank for referring you? __________________________________________________(Relative, Friend, Yellow-Book, Online Search)Have you had previous Acupuncture Care? ? Yes ? NoApproximate date of your last visit? ____________________________________________________Addressing What Brought You Into This Office:Health Concerns:(Please list by severity)Rate of Severity1 = Mild10 = Worst ImaginableWhen did this episode start?(Days, weeks, months or years ago?)Have you had this condition before? When?Did it begin slowly, immediately, or with an injury?% of the time your pain is present1.2.3.4.5.In General, What Symptoms Do You Experience: ? Pain ? Muscle Spasm? Stiffness? Numbness ? Headache ? Tingling? Swelling? Tightness ? WeaknessQuality of Your Symptoms: ? Sharp ? Throbbing? Burning? Dull ? Local? Tension? Aching? Radiating Since Your Symptoms Started, Are They: ? About the Same? Getting Better? Getting Worse What Have You Done to Help Your Condition? ? Ice ? Heat ? Pain Relievers? Massage ? Stretching What Activities Aggravate Your Condition?? Sitting ? Concentrating? Running? Standing ? Dancing? Shoveling? Working? Chores ? Sleeping? Bending ? Dressing? Walking? Carrying? Driving? Lifting? Climbing? PushingHave You Seen Anyone Else for This Condition? (Chiropractor, Family Practitioner, MD, Etc.)? Yes ? NoGeneral Health HistoryHave you ever had any of the following diseases or conditions? Chiropractic is concerned with how your nervous system is functioning. If it is not functioning at 100%, a multitude of problems can occur. CERVICAL SPINE (Neck): Do you experience…?? Neck Pain ? Headaches ? Sinusitis/Allergies? Pain into Shoulders/Arms/Hands ? Dizziness ? Numbness/Tingling in Arms/Hands ? Visual Disturbances ? Coldness in Hands ? TMJ/Pain/Clicking THORACIC SPINE (Upper back): Do you experience…?? Heart Palpitations/Murmurs ? Recurrent Lung infections/Bronchitis? Asthma/wheezing? Heart Attacks/Angina? Pain into Ribs/Chest? Mid-Back Pain ? Pain on Deep Inspiration/Expiration? Ulcers/Gastritis? Indigestion/Heartburn/RefluxLUMBAR SPINE (Lower back): Do you experience…?? Pain into Hips/Legs/Feet ? Recurrent Bladder Infections ? Low Back Pain? Numbness/Tingling in Legs/Feet ? Frequent/Difficulty Urinating ? Constipation/Diarrhea? Coldness in Legs/Feet ? Muscle Cramps in Legs/Feet ? Menstrual Irregularities/Cramping Accumulations of Stress The following areas of stress can contribute to your loss of health and influence our body’s ability to heal and repair. PHYSICAL STRESS? Slips/Falls ? Sleeping Position ? Repetitive Heavy Lifting? Continuous Sitting/Standing EMOTIONAL STRESS ? Relationships ? Career ? Loss of Loved OneCHEMICAL STRESS? Tobacco Use ? Prescription/Over the Counter Drug Use? Poor Diet Please List All Medications, Supplements, Vitamins, and Homeopathic Remedies You Presently Use or Take:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please List Hospitalizations, Accidents, or Surgeries Not Mentioned with Dates:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Informed Consent for Acupuncture CareWhen a patient seeks acupuncture health care and we accept a patient for such care, it is essential for both to be working for the same objective. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. You have the right, as a patient, to be informed about the condition of your health and the recommended care and treatment to be provided so that you may make the decision whether or not to undergo acupuncture care after being advised of the known benefits, risks and alternatives.Acupuncture is a science and art which concerns itself with the relationship between the body's Qi and function as that relationship may affect the restoration and preservation of health. Health is a state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.Acupuncture is an effective form of health care that has evolved into a complete and holistic medical system. Practitioners of acupuncture and Chinese medicine have used this noninvasive medical system to diagnose and help millions of people get well and stay healthy.An acupuncturist will place fine, sterile needles at specific acupoints on the body. This activates the body's Qi and promotes natural healing by enhancing recuperative power, immunity and physical and emotional health. It can improve overall function and well-being. It is a safe, painless and effective way to treat a wide variety of medical problems. If during the course of care we encounter non-acupuncture or unusual findings, we will advise you of those findings and recommend that you seek the services of another health care provider.All questions regarding the doctor’s objective pertaining to my care in this office have been answered to my complete satisfaction. The benefits, risks and alternatives of acupuncture care have been explained to me to my satisfaction. I have read and fully understand the above statements and therefore accept acupuncture care on this basis.Authorization for CareI hereby authorize the Doctor to work with my condition through the use of acupuncture to my body, as he or she deems appropriate. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. If the Doctor does accept my case, it does not guarantee nor does it imply a guarantee of being able to cure or prevent any condition, illness, or injury.I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care, any fees for professional services rendered me will become immediately due and payable.Guarantee of PaymentI clearly understand and agree that all services rendered me are charged directly to me at the prevailing rates and that I am personally responsible for payment. I have been advised that this office offers all patients and third party payers a discount for services when the services are paid in full at the time of service or pre-paid in advance of services. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. ______InitialAcknowledgement for Consent to Use and Disclosure of Protected Health InformationYour protected health Information will be used by Pathways Chiropractic & Wellness and may be disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of this office.Notice of Privacy PracticesYou should review the Notice of Privacy Practices for a more complete description of how your Protected Health Information may be used or disclosed. It describes your rights as they concern the limited use of health information, including your demographic information, collected from you and created or received by this office. I have received a copy of the Notice of Patient Privacy Policy. ______InitialRequesting a Restriction on the Use or Disclosure of Your InformationYou may request a restriction on the use or disclosure of your Protected Health Information.This office may or may not agree to restrict the use or disclosure of your Protected Health Information.If we agree to your request, the restriction will be binding with this office. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards.Revocation of ConsentYou may revoke this consent to the use and disclosure of your Protected Health Information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.Appointments are reservations made exclusively for you. Missed appointments will be billed a charge of $50. Please give at least a 4 hour notice if you cannot keep your appointment.Balances that are not paid within 30 days of receipt of statement will incur a $5 late fee.Balances that are not paid within 4 months of the date of service will be turned over to our collection agency.By signing below I am agreeing to paragraphs I-VII.X_________________________ ____________ ___________________________ _______ Patient Signature Date Parent/Guardian Authorizing Care Date ................
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